Paris, France - ACE inhibitors are beneficial in patients with stable coronary artery disease who have no left ventricular dysfunction or heart failure, a new meta-analysis, published in the April 10, 2006 issue of Archives of Internal Medicine,has found [1].

The lead investigator of the study, Dr Nicolas Danchin (Hôpital Européen Georges Pompidou, Paris, France), told heartwirethese findings should persuade the European Society of Cardiology (ESC) to include ACE inhibitors in its upcoming recommendations for the treatment of stable angina.

Use of these antihypertensive agents long term significantly reduced total mortality and major cardiovascular end points in this patient population and "suggest that ACE-inhibitor therapy should be systematically used in all patients with documented CAD," the French researchers say.

In 2003, the HOPE and EUROPA studies suggested that high-risk coronary patients without heart failure or left ventricular dysfunction could gain additional cardiovascular protection with the addition of an ACE inhibitor to therapy. In October 2004, the American College of Physicians (ACP) published a recommendation based on these two trials that all patients with coronary heart disease should be taking an ACE inhibitor.

But just a month later, the results of another mega-trial, PEACE, showed that giving the ACE inhibitor trandolapril to a similar patient population provided no added benefit.

So Danchin and colleagues searched the literature for comparable randomized controlled trials with follow-up of two years or longer. As well as HOPE, EUROPA, and PEACE, they found four other studies—QUIET, PART-2, SCAT, and CAMELOT—for a total of 33 960 patients followed for a mean of 4.4 years.

Treatment with ACE inhibitors significantly decreased overall mortality, cardiovascular mortality, myocardial infarction, stroke, and other end points.

Danchin explained to heartwire that "there was a general feeling when PEACE was reported that the patient population was at very low risk and that maybe ACE inhibitors were not necessary once patients were being optimally treated."

But he argues that the PEACE population "was not so different from that in EUROPA," and he says that PEACE probably failed to show a benefit of trandolapril because the dose used was too low, especially given the fact that more than 80% of the participants were North American and many were overweight or obese.

"It's quite clear to me from this meta-analysis that ACE inhibitors are beneficial in this patient population," he says. "They reduced total mortality, cardiovascular mortality, acute MI, and a number of other secondary end points."

The new ESC guidelines on stable CAD, which are pending, should therefore clearly include a recommendation to use ACE inhibitors, he concludes.